ICD-10 Coding for Low-grade Squamous Intraepithelial Lesion(R87.614, R87.610)
Complete ICD-10-CM coding and documentation guide for Low-grade Squamous Intraepithelial Lesion. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Low-grade Squamous Intraepithelial Lesion
R87.61Primary Range
Abnormal findings in cytological and histological examination of female genital organs
This range includes codes for cytological findings in cervical screening, specifically LSIL.
Encounter for screening for malignant neoplasm of cervix
Used for routine cervical cancer screening encounters.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R87.614 | Low-grade squamous intraepithelial lesion (LSIL) on cytologic examination of cervix | Use when LSIL is confirmed on cytologic examination without ASC-H. |
|
| R87.610 | Atypical squamous cells, cannot exclude HSIL (ASC-H) | Use when ASC-H is documented alongside LSIL. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for LSIL
Essential facts and insights about Low-grade Squamous Intraepithelial Lesion
Primary ICD-10-CM Codes for lsil
Decision Criteria
clinical Criteria
- Confirmed LSIL on cytologic exam
documentation Criteria
- Detailed cytologic findings and HPV status
Applicable To
- LSIL
Excludes
- HSIL (R87.611)
Clinical Validation Requirements
- Cytologic examination confirming LSIL
- HPV test results if available
Code-Specific Risks
- Misclassification as HSIL
- Omission of HPV status
Coding Notes
- Ensure documentation specifies LSIL without ASC-H unless both are present.
R87.610 - Atypical squamous cells, cannot exclude HSIL (ASC-H)
Use when ASC-H is documented alongside LSIL.
Applicable To
- ASC-H
Excludes
- LSIL without ASC-H
Clinical Validation Requirements
- Cytologic examination indicating ASC-H
- Biopsy results if available
Coding Notes
Ensure both LSIL and ASC-H are documented if using this code.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Low-grade Squamous Intraepithelial Lesion to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R87.614.
Impact
Clinical: May lead to inappropriate follow-up care., Regulatory: Non-compliance with documentation standards., Financial: Potential denial of claims due to insufficient documentation.
Mitigation Strategy
Use specific terminology like LSIL, ASC-H, Document HPV status
Impact
Reimbursement: Incorrect DRG assignment leading to potential overpayment., Compliance: Non-compliance with ICD-10 coding guidelines., Data Quality: Inaccurate clinical data affecting patient management.
Mitigation Strategy
Use R87.614 + R87.610 for LSIL-H if both are documented.
Impact
Risk of coding LSIL-H as HSIL without proper documentation.
Mitigation Strategy
Ensure documentation specifies both LSIL and ASC-H.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Low-grade Squamous Intraepithelial Lesion, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Low-grade Squamous Intraepithelial Lesion
Use these documentation templates to ensure complete and accurate documentation for Low-grade Squamous Intraepithelial Lesion. These templates include all required elements for proper coding and billing.
Routine Pap Smear with LSIL
Specialty: GynecologyRequired Elements
- Patient demographics
- Reason for visit
- Cytology results
- HPV status
- Follow-up recommendations
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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